Overheated patients were dying around her, and only a few could be taken away by helicopter, the only means of escape for the most fragile patients until the water receded. Medicines were running low, and with no electricity, patients living on machines were running out of battery power. In the chaos, Dr. Pou was left to care for many patients she did not know.

The Attorney General contends that Dr. Anna M. Pou and two nurses gave lethal injections to at least four patients:

At least three employees said Dr. Pou had talked of administering “lethal doses” of morphine to those patients. One also saw her with packs of morphine and syringes, and another witness said that out of the corner of her eye, she saw one of the two nurses inject one of the patients with something.

If I were called to the jury, I'd have to hear some truly unexpected evidence to want to convict her or the two nurses. From what I know of the conditions there, if my elderly mother or critically ill loved one had been dying, painfully, in the heat with no water, lying in her own waste, with no electricity, no light, not even a fan moving the air, no oxygen, well, I'd have been praying for someone to take the edge off of that fear and pain.

Thirty-four people died in that hospital in those four days. Lots lived, and they were evacuated later. But the fact that so many died, so quickly, tells me conditions were such that for the most critical, it was probably inevitable.

There may well be startling facts that we haven't heard, but until I do, these women are innocent until proven otherwise.

The AG, Charles Foti, used to be our sheriff, and under his supervision, you didn't want to end up in jail if you had diabetes, asthma or heart disease. More than a few such people died while in custody, for lack of care.

This is a meaty one. Morphine administered near the end is unpredictable, I know, so before reading the story my sympathies lay with the doctor and nurses.

But the evidence cited overcomes my concern at the headlined question, and makes me value another question: how do we expect doctors to act who stay behind for the next storm?

"The affidavit released Tuesday by Mr. Foti’s office quoted several hospital employees describing meetings in which, they said, Dr. Pou talked about patients who 'were probably not going to survive.' At least three employees said Dr. Pou had talked of administering 'lethal doses' of morphine to those patients."

Mr. Foti ... said a grand jury working under the direction of the Orleans Parish district attorney would decide whether to bring formal charges.

'This is not euthanasia,' Mr. Foti said, accusing the three women of playing God with at least four patients, ranging in age from 61 to 90. 'This is plain and simple homicide.'"---------

Perhaps it's good that this will go before a grand jury, to hear all of the findings. While the tragedies of the storm might mitigate some actions and minimize punishment perhaps, it can't excuse everything deliberate, even in good intention. Particularly if the 61-year-old is family, was loved, did not consent to be helped die, and would have had family members there except for the storm conditions. Dr Pou's not facing negligence charges for leaving the patients alone, to live or die on their own, afterall.

Put me down as: Good for the system to have a grand jury hear the findings. (no visuals, but that was still fun!)

Also, the hospital evacuation was hair-raising. It's likely patients with no chance of surviving it would have been left to die alone, in the conditions described, and with armed looters roaming the hospital. It's really diffficult to understate the horror of the conditions at Memorial. There's some cynicism here because the families of these four people are surrounded by personal injury lawyers and no longer talk to the press. One of these patients was 90 years old, another was due to have both legs removed due to diabetes and both were gangrenous. How do you think she fared in 110 degree heat for four days?

I believe the prosecution will try to show that the doctor acted out of self-interest, out of fear that without eliminating some of the worst cases, she wouldn't be able to cope with the rest, or perhaps not even be able to evacuate. That doesn't square with what I've heard about the actions of medical personnel in hospitals all over town, including this one. But I'm open to evidence. I'm also curious as to what other medical people who stayed, perhaps at different faciities, think about this.

Jennifer, no one knew how bad the situation was going to get. The canals and levees breaking changed a terrible storm into something much worse. No one expected water to fill 80 percent of the city and stay for three weeks.

Like Elizabeth, I am not impressed. Until I read of some unexpected evidence, this seems to me to be not much more than looking for a convenient scapegoat for the criminal negligence of others. Someone should pay, and pay dearly for the mess in New Orleans, and the doctor and nurses are convenient and easy targets, while the city, state, and federal officials aren't.

I can imagine how this will go: autopsy reveals X had morphine in his/her system at time of death. Therefore, the doctor murdered X. It won't matter if X had morphine as a matter of treatment in the days before Katrina. Hard to imagine these people getting a fair trial in New Orleans.

Elizabeth - And I can't think of a recent example of hospital patients faring so badly. Who could have foreseen that? I only asked as I wonder if the families of these patients are looking to assauage their own guilt (misplaced though it may be) by pinning evil on a caretaker.

Jennifer, that's certainly possible, isn't it? They must feel terrible for having had to leave their families behind. But again, I have to emphasize, we all believed we'd be back home within a few days, maybe a week. The people who were in charge of inspecting and maintaining the levees knew this could happen, but they'd been awfully quiet about it.

Mary, I'm pretty sure experienced medical professionals have a little more to go on than Bible verses, but we'll have to disagree on that.

Ronin: Hard to imagine these people getting a fair trial in New Orleans. I think they will get a fair trial here. In fact, the sympathy on the street is with the doctor and nurses. Dr. Pou got more than 10 calls in an hour from lawyers offering to defend her at no charge.

Nobody knows in all circumstances Elizabeth, even your most experienced medical professionals, who will be the first to tell you that.

Absent other instructions, better that the person's body shut down on its own, as many did, during transportation/evacuation procedures than injecting a lethal combination. That's Medicine 101.-----

Eugene Myers, a professor at the University of Pittsburgh who helped train Dr. Pou ... said Dr. Pou had told him that she and Lori Budo and Cheri Landry, two nurses who have also been arrested in the case either helped evacuate the last patients or tried to make them comfortable with pain medications.

Asked about the accusation that she had given the patients lethal doses, he said: “That is not in the character of Anna Maria Pou. Here’s a woman whose absolutely dedicated to excellence in patient care.”------

If it becomes more clear that the doctor did deliberately administer lethal dosages, that crosses a line. Emotions and circumstances aside, the state and hospital systems are obliged to have people's trust. Again, one can't assume that what your mother wants is what mine wants also.

Elizabeth: I think they will get a fair trial here.That's good to hear. I hope so. I read some contemporaneous accounts of preparations for evacuation at the time. The difference between what HCA was prepared to do, and did, to get their patients out of harm's way, and what Tenet Healthcare failed to do was stunning.

It's not up to the doctor to decide when I've had enough. I could be in extreme pain and discomfort, but that would not necessarily mean that I'd like to be killed. Some people might rather go through all that horror to at least have a shot at survival.

I agree with Ann. When all is said and done, the subtleties of the situation will be lost in the retelling, and the enduring message will be "abandon the patients, turn tail and run with all the rest of the doctors, lest you end up like Dr. Pou."

See, it's ok (as far as being indicted) to book on out of town, but if you stay, we're going to be watching you. It was something similar to this kind of thing (absent the morphine, which I admit does no favors to my analogy) that prompted the enactment of Good Samaritan laws, wasn't it? Of course, I'm presuming innocence here, which is what we're supposed to do, right?

Lack of an evacuation plan in what can only be described as 'Hurricane Alley' can also be called 'rolling the dice' every year.

It is clear that New Orleans, indeed the entire state of Louisiana, never sat down and considered the worst case scenario. Did they learn nothing from the deaths in Europe (France) years ago when so many of the elderly and infirm died in a heat wave while their family was vacationing on the Mediterranean?

This situation is criminal to the degree it was preventable. We are all responsible, as advocates for own health and the health of our family members, to question providers with "What if?"

These people didn't have their head in the sand, they had their collective heads somewhere else! They all deserve a grand jury investigation.

I am glad you opened this thread, Ann--I work as a local emergency response coordinator for a health district; we are currently doing pandemic flu planning. The situation in New Orleans brings into sharp focus our dilemma: We dont have enough intensive care units or ventilators to take care of the patients anticipated with the CDC projections--we need 17 ventilators; we have three, two of which are in use.

Who gets the vents? Who gets the ICU units that we know we dont have enough of? How are these decisions made? I will tell you that NO one, not Governor Gregoire, not Julie Gerberding, not the state health officer will go on the skyline and provide any guidance at all prior to the flu--and I dont anticipate any help during a pandemic--see the Katrina disaster for what really happens.

So how do we proceed? esp knowing health care professionals might be prosecuted afterwards. Here's a real life issue we can anticipate and plan for before hand--Any suggestions from your blog readers?

(PS: our County Health Officer is trying to put together an ethics committee from local providers to wrestle with this and come up with guidelines)

I'm wondering the same thing. I'm wondering if Dr. Pou was overheard discussing patients who asked for the lethal doses or if she was overheard discussing taking matters into her own hands. Either way, not legal. But, I'm wondering.

Any hope of a Queens Bench v. Dudley (the old lifeboat case)? Some criminal liability to make a statement, then mercy on the backside because she really had no choice it seems or reasonably appeared to have no other choice? I know the facts are distinguishable.

Of course she will be sued mercilessly in civil court. Leaving Granny in a home and then not going to get or even check on her in a hurricane should not be the lottery. If there are children and grandchildren to these 4 souls they should be ... I can't think of anything right now, but Dante would have a proper spot for these folks.

Elizabeth... I hope you're right about the New Orleans "street" being pro-Doctor here. The case seems extraordinary enough that an exception can be made without making a new general rule.

Freeman Hunt--I think your comment is clearly the "bright line" strategy; and I am assuming it is the difference between active and what I would term passive euthansia; but, lets take the vent situation--do we take someone off a vent to give it to someone else? Do we tell people you could be saved with intensive care but we cant get you in?

We don't know all the facts, but it does seem like a wrongheaded prosecution. If Dr. Pou had injected these patients the day before Katrina, okay, but this happened days after.

Freeman, your standard is fine in normal circumstances, but the choice here seemed to have been "die now" or "die in agony later." At that point, the Memorial Ethics Committee could not be convened to ponder the nuances!

Doctors and hospitals face tough choices all the time; they withhold treatment, they give big doses of pain meds.

Lack of supplies for an emergency is a construct imposed on the local populace by elected government and insurance companies.

The latest trend broke down the cost of functions provided by doctors and medical staff (indeed most managers across the spectrum) into discreet activities. These discreet activities were then parceled out to sub-contractors who commercialized the art of medicine into medicine for profit.

I am certain there exists an actuarial table somewhere that calculates the cost of litigation for X number of deaths/injury versus cost savings. There is also the 'let them bleed out' crowd who know the end is near for a given patient and any life extending medication/care is quietly withheld absent intervention by an advocate.

I can hear the defendant's thundering rhetoric blaming Katrina in it's defense of financial limitations. Very little will be said about the elephant in the waiting room; cost to benefit analysis versus human life.

Is it possible, as her colleagues seem to be implying, that she simply dosed patients with morphine to ease their pain and they died due to the heat and other factors?

That is pretty much my line of thought. I suppose I understand the need for a Grand Jury hearing and I am glad to hear of the support for Dr. Pou and the nurses. It just angers and frustrates me when things get to such a point. Those accusing her of playing God can also be accused of playing God in that they have not the remotest notion of the difficulties and stress she and her nurses were facing with pain and death all around and being helpless to administer as they were trained and obligated to do. They stayed by choice under catastrophic circumstances.

ps....... you link is http://http://www.nytimes.com/2006/07/20/us/20doctor.html? making it inaccessible. I had to google eliminating the extra 'http://'

I'm reading things on both sides of this issue that are making me think. I have come to the conclusion that this topic isn't one that I can sit back and enjoy debating. After I participated briefly this morning, I found myself in tears--not a gusher, just a little weepiness--on the drive to school, and had to sit in my office and compose myself before going into class. Don't worry; this is standard post-Katrina operating mode. I found myself passing houses where I know people drowned, and thinking of an old folks' home where too many residents died, waiting to be evacuated more than a week after the storm. It's going to be a hard, hard road for those who are stuck judging this case.

It may bear mentioning that the penalty for second degree murder in La. is mandatory life in prison with no parole.

"the penalty for second degree murder in La. is mandatory life in prison with no parole."

It's possible to imagine a scenario in which Dr. Pou is guilty of 2d degree murder in the literal sense, and yet undeserving of this penalty. The situation demonstrates why overly rigid sentencing guidelines are unjust.

That said, isn't it more likely, from what we know of Dr. Pou's career and reputation, that her intent was to relieve the patients' suffering rather than to kill them? Under the chaotic circumstances, there was a substantial risk that patients as ill as these would not survive, whatever she did or didn't do.

It is okay to kill people if you do it for the right reasons, especially if you're a doctor.

This woman is more of a hero than a villain. Being a doctor, she knew for certain who would live and who would die, so she just made their death's better than they would have been. And it is right for her to make that choice. I mean she is a doctor and these patients were really, REALLY old.

Having said that, she shouldn't be convicted of murder anyway, because it was impossible for her to know exactly how the morphine would effect her patients.

Is it possible, as her colleagues seem to be implying, that she simply dosed patients with morphine to ease their pain and they died due to the heat and other factors?

My spouse is an anesthesiologist and we have discussed the use of high powered pain killers in critical patients. There is always a fine line to be walked with them, as all the opioids depress respiration and other body functions. Too much kills, too little leaves the patient in pain and it's darn hard to figure out what doses to use in critical patients.

Another point - pain is now considered a vital sign, just like pulse, etc. and there is now an emphasis on pain control in hospitals.

So take all this and put it into a blender and there could have been some unfortunate outcomes that were not intended.

Freeman Hunt said...Did any of the people ask to be killed? If not, I'd call it homicide.

It's not up to the doctor to decide when I've had enough. I could be in extreme pain and discomfort, but that would not necessarily mean that I'd like to be killed. Some people might rather go through all that horror to at least have a shot at survival.

No, you are guaranteeing - as are others prosecuting and suing the medical staff by their views, that patients can pretty much forget about mercy in catastrophic circumstances.

You are saying the safest and only path is for Staff to CYA and walk away leaving the abandoned to die alone, in fecal waste and maggots eating their flesh. Otherwise, you claim, it's homicide.

You presume it's a matter of "choice" as if a magic wand could be waved - the hospital magically functional again, family members who refused to be with their senile elderly magically showed up to give permissions. The criminal thugs penetrating the hospital and declining conditions that had doctors and nurses instructed to evacuate and continue to try and expend their efforts in triage on who could be saved magically all were fixed.

So it would all be "your choice" --- as plenty of people and resources attended your dying wishes.

This was a circumstance where the police that were supposed to guard the hospital and protect staff - had seen half it's members desert and bug out of New Orleans. Of the doctors and staff at the hospital not showing up for work, or as conditions deteriorated, bailing on their patients. This doctor and the two nurses were among the last of the hardcore caregivers that had stuck with their duties until the last evacuation helicopters were set to take off, and their reward is murder charges.

That sends a powerful lesson to every medical professional in a dire local or national emergency that it is best to walk away from people in need rather than risk criminal or million dollar tort lawsuits for any alterations in caregiving and medical efforts, intervention not consonant with the levels they would be expected to do in a perfect hospital in perfect circumstances.

The Freeman Hunt perspective is if you see an badly injured, gravely ill, or dying person in a catastrophe - if you are a medical professional or just a layman....unless your intervention will not be seen in 20-20 hindsight as "perfect", doing no harm.....it is the least personal risk ending up in jail or sued for everything you have to NOT GIVE AID - but just walk away and let them die.

Hopefully, a jury nullification will avoid punishing the last caregiver holdouts who stayed in a Hellish place for almost a week while their liability free peers either never showed or fled. But the chilling effect on other dedicated emergency workers is obvious...

Hunt - I could be in extreme pain and discomfort, but that would not necessarily mean that I'd like to be killed.

Exactly. The presumption for many medical workers in the future will be that since they can't know, the default position is the minority one - which assumes since a small but real patient preference for a long, slow, excruciatingly painful death with no pallative care cannot be ruled out - the professionally safe path is to assume ALL patients they cannot help should be abandoned to that fate.

Cederford--I asked for opinions earlier in the thread in the light of what public health professions know will be the situation in the event of a pandemic flu--and quite frankly, the responses I have seen fully support your analysis. It will certainly make it a lot easier for us to send them home knowing they will die a very unpleasant death from respiratory distress or multiple organ failure.

And for what it is worth, I volunteer for Katrina epidemiological duty but withdrew my application when I found out the State of Washington would not indemnify as a volunteer.

Pat, that's a good way to put it. It's going to be hard enough in a jury room. I don't expect to avoid it, though. This will be a big issue for the near future, here.

cedarford, one reason I'm sceptical about these charges is that one of the only sources is a doctor who said he overheard some vague conversations, and decided to leave so he wouldn't have to deal with the situation. I don't know what kind of witness he'd make; the conversations might have been just the kinds of things people say when they're worried, like "What do we do if help doesn't come, and these patients are in intolerable pain, dying?" -- his response was "I'm outta here!" Now he's the witness against the people who stayed, who got their patients evacuated, who cared for people in the heat, the dark, against terrible odds? How can he know what happened after he covered his ass and left those patients without the benefit of his care?

It occurs to me that the fact that injected drugs were used medicalizes the situation in a way that may make analysis harder. (We associate drugs and injections with medical professionals, with curing, with technical expertise.)

Supposing that this doctor had strangled these people, instead of injecting them with morphine and sedatives. (Maybe the drugs were unavailable; maybe a decision was made to save them for patients who were to be allowed to live. Either one is plausible.) Supposing that she had offered as her justification that she was offering "mercy", that they would probably have died anyway, that they were in discomfort, that the evacuation was very difficult - all justifications that have been proposed here, and some she is alleged to have offered at the time.

Do you still feel the same about her alleged actions, if she used some method of killing other than injecting drugs? If not, why not?

The Freeman Hunt perspective is if you see an badly injured, gravely ill, or dying person in a catastrophe - if you are a medical professional or just a layman....unless your intervention will not be seen in 20-20 hindsight as "perfect", doing no harm.....it is the least personal risk ending up in jail or sued for everything you have to NOT GIVE AID - but just walk away and let them die.

Uh, no. That's not even remotely what I wrote.

This has nothing to do with perfect vs. non-perfect medical care. It has to do with purposeful killing (i.e. murder) or not. If she didn't kill them on purpose, fine. If she did, she's a murderer.

As a Registered Nurse, I have a few things to offer on this debate. First of all: The Doctor took an oath to do no harm, as did those nurses. They are ethically bound by their profession not to commit intentional harm. Second of all, we don't know the sepcifics of the situation. I'll touch on the logistics of it first. I work in major inner city hospital Intensive Care unit. If the power goes out, the ventilators and IV pumps only have so much battery power. Maybe four to six hours, max before you start to have negative repercussions for your patients, maybe. Aftet the IV pumps go out, well, ok, you can place them on a gravity drip. To provide airway support, you will need to do what we refer as 'bagging' where a rubber bag is connected to an endotracheal tube and squeezed to push air into a patient's lungs. It lasts only as long as there is staff to squeeze it, and how long can one survive being bagged? We don't know, as there are not exactly volunteers to find out. Sonme of the people in the ICU are so sick the we can't keep them alive with all our resources functioning at capacity, so how do you care for critically ill patients with no mionitoring systems, no supplies, no medications, no equipment, and no one to help? You don't. The patients will most likley die, with or without outside intervention. That being said, I would have a herd time as a fellow professional sitting on that jury hearing the circumstances and convicting those nurses. On one hand, we are taught to ease human suffering. It is the humane, compassionate thing to do. It is a responsibility not to abandon our patients, and to keep them as comforted as possible. On the other hand, it is against both the law and our professional code of ethics as nurses to 'knowingly administer deletorious medications'.Your choice: No help appears to be coming. Do you leave them there to die a humid, watery death, lying in their own waste, or do you ease their suffering, and help them be comfortable as possible for as long as you can?Motives and ethics play a large part in this.

****The Freeman Hunt perspective is if you see an badly injured, gravely ill, or dying person in a catastrophe - if you are a medical professional or just a layman....unless your intervention will not be seen in 20-20 hindsight as "perfect", doing no harm.....it is the least personal risk ending up in jail or sued for everything you have to NOT GIVE AID - but just walk away and let them die."****

As a side note, Freeman Hunt, most states have what are called "Good Samaritan Laws" These laws act as a shield to protect you from lawsuits if you act as prudently as possible within your scope and training. If I roll up on an accident scene with my buddy who is an EMT and there is a severely injured person that needs assistance, and we attempt everything that is within our roles as an RN and an EMT we should be covered by law. If we attempted something that is outside of our 'Scope of Practice' we could be held accountable. For example, assuming that we had supplies, we could initate cervical spinal precautions and place an endotracheal tube. we could not perform an emergency cricothryotomy as it is not in a EMT-B's scope of practice and sure isn't in mine. The rule of thumb is, if you have been properly trained, and liscenced, you can do it in the field as an emergency treatment and be reasonably safe from lawsuits. Don't cross your professional lines though.

Please, Please don't let the fear of lawsuits stop you from stopping to help at an accident scene. Sometimes wuite literally minutes count.

As a side note, Freeman Hunt, most states have what are called "Good Samaritan Laws" These laws act as a shield to protect you from lawsuits if you act as prudently as possible within your scope and training.

“This is not euthanasia,” Mr. Foti said, accusing the three women of playing God with at least four patients, ranging in age from 61 to 90. -------"It is okay to kill people if you do it for the right reasons, especially if you're a doctor. This woman is more of a hero than a villain. Being a doctor, she knew for certain who would live and who would die... I mean she is a doctor and these patients were really, REALLY old." -------"You're funny harkon. Sounds like you get the community you deserve, age/class expectation included."

I only meant, in my circles 61 and seventies are not really, REALLY old. Plus, your insistence in these times, that doctors always know best, up to being able to predict date of death, seemed laughable, like you were trying to be funny here. If not, well I doubt you'll make it into your 80s with that attitude; have you spend anytime around older, people winding down? Any chance that doctor might be might have unconscious predjudices in choosing who she thinks has a chance at making it, thus no lethal morphine/plus "combination" -- a key that mix, if you read the article -- and who she decides not to inject, giving their bodies a fighting chance? After a friend's stroke, they told us she'd be dead within a week. We got to have her for another 5+ years, and yes, her body was debilitated -- she never walked again, mostly I think because her doctor predicted death, and there was no immediate attempt to get her back on her feet right away. The weeks of pt therapy, approved after she didn't die, might never have worked or maybe it just came too late? Still, she enriched my life in those final 5 years, and don't be cynical and think I mean money here. It's the spirit inside, the accumulation of skills in years of living -- whether it be recipe-making or book knowledge -- that still exist in those final years, even if it comes and goes, that make some people press on to live, despite uncomfortable, perhaps even painful, physical limitations.

If my friend's doctor had been given extra special skills and acted like a vet in deciding it was better to painlessly "put her down" after the stroke, her family and friends would have missed out on seeing this chapter of life, and celebrating the holidays, birthdays, and just everyday moments like watching the hummingbird at the feeder. I know some people would think it undignified to go on "living" like that -- needing help with the basics -- but I think some would still want to live, knowing the ones they cared for all those years would now be there for her -- taking care until the end, when she and her body decided it was finally time to go.

The catastrophe of Katrina may have separated some caring families from their aged and ill. To call these families selfish though, without knowing the specific circumstances, seems ugly to me. Specifically, addressing race -- some people don't have much confidence in hospitals/doctors to begin with, often based on solid reasons that are stretched (Tuskeegee study?) People having faith that the doctors will not make the arbitrary decision to put someone down without consent, is important in society too.

I never said I was unwavering in my moral convictions, just that I could envision another side than "these people are old, the doctor is always right, goodbye to you." I do acknowledge though, that my way of thinking and valuing, are probably a throwback and in the minority now; as a society, we value different things and older ill people aren't seen as contributing all that much anymore.